ASPIRE Obstetric Anesthesia Subcommittee Meeting
December 11, 2019
Agenda
Introductions & Membership
Sharon
Abramovitz, Weill Cornell
Angel Martino, Sparrow Health System
Ami Attali, Henry Ford
- Detroit
Arvind
Palanisamy, Washington University
Melissa Bauer, Michigan Medicine
Carlo Pancaro, Michigan Medicine
Dan Biggs, University of Oklahoma
Mohamed
Tiouririne, University of Virginia
Traci Coffman, St. Joseph Mercy Ann Arbor
Brandon Togioka, Oregon Health Science University
Eric Davies, St. Joseph Mercy Oakland
Joshua Younger, Henry Ford, Detroit
Ghislaine Echevarria, NYU
Langone
Marie
-Louise Meng, Duke
Ronald George, University of California
- San Francisco
Nirav Shah, MPOG Associate Director
Jenifer Henderson, St. Joseph Oakland
Katie Buehler, MPOG Clinical Program Manager
Rachel Kacmar, University of Colorado
Meridith
Bailey, MPOG QI Coordinator
Joanna Kountanis, Michigan Medicine
Brooke Szymanski, MPOG QI Coordinator
Will post slides to the MPOG website for those who could not attend.
What is MPOG?
• Formed in 2008
• Academic and community hospital
consortium. Includes over 40 hospitals
across the country (and 2 in the
Netherlands)
• Aggregates data
• Dual mission of research and quality
improvement
What we have achieved so far
• Demographic Information
• Preoperative H&P
• Medications / Infusions / Fluids / Outputs
• Physiologic values/ Laboratory values
• Intraop events
• IV Access
• Staff in / out
• Professional fee CPT codes
• Discharge ICD 9/10 codes
• Outcome record / Outcome registry
49 institutions, 5 EHR vendors
~12 million cases extracted,
mapped, de-identified, and
available for QI and research
~75 million medication doses
24 billion physiologic
observations
MPOG
Research
Quality
(ASPIRE)
BCBSM
funded
program
Not drawn to
scale
ASPIRE is the quality improvement arm of the
Multicenter Perioperative Outcomes Group
OB Subcommittee: Where we left off…
• Met last in September 2017
• Reviewed existing MPOG measures for applicability to obstetric anesthesia
– Modified exclusion criteria for TRAN 01/02; Exclude cases with:
– 1. ICD 10 codes indicating postpartum hemorrhage
– 2. VS Changes (HR>110, BP≤85/45, O2 sat<95%) or EBL ≥1500cc for patients undergoing
caesarean section (CPT: 01961, 01968, 019262, 01963, 01969)
– 3. Labor epidural cases.
– 4. In the future, account for ≥ 15% change in vital signs from baseline (MPOG still does not
capture baseline VS reliably.)
– Modified success criteria for TEMP 01 to include fluid warming as an acceptable means warming
for patients undergoing Caesarean Delivery.
– Did not add exclusion criteria for AKI 01 to exclude patients diagnosed with preeclampsia or
eclampsia using ICD 10 codes: cases flagged for provider review
ASPIRE Measures including Cesarean Delivery Cases
(but not labor epidurals)
– AKI 01
– BP 01
– BP 02
– BP 03
– CARD 02
– CARD 03
– GLU 01
– GLU 02
– NMB 01 (with GA only)
– NMB 02 (with GA only)
– PONV 01 (with inhalational GA only)
– PONV 02 (with inhalational GA only)
– PUL 01 (with GA-ETT only)
– PUL 02 (with GA-ETT only)
– PUL 03 (with GA-ETT only)
– SUS 01 (with inhalational GA only)
– TEMP 01
– TEMP 02 (with GA only)
– TOC 01
– TOC 03
– TRAN 01
– TRAN 02
See MPOG website for measure specifications: https://mpog.org/quality/our-measures/
ASPIRE Measures including both Labor Epidurals & Cesarean Deliveries
• MED 01
• FLUID 01-NC
• PONV 03
ASPIRE Measures excluding all obstetric cases:
• TEMP 03
• TOC 02
• FLUID 01-C
See MPOG website for measure specifications: https://mpog.org/quality/our-measures/
Next Steps: OB Specific Measures
• Review MPOG Cesarean Delivery Data
• Call for Measures: Survey Results
• Review Draft Measure Specifications
– Prolonged hypotension before cesarean delivery
– General Anesthesia Rate for Cesarean Delivery
• SOAP Centers of Excellence Criteria
• Inclusion Criteria – Case types to focus on?
MPOG Cesarean Delivery Data
• 260,062 cesarean deliveries in MPOG database
• 1/22/2004-11/30/2019
• 52 Institutions represented
• Identified using anesthesia CPT codes:
– 01961: Anesthesia for cesarean delivery only
– 01968: Anesthesia for cesarean delivery following
neuraxial labor analgesia/anesthesia
More Cesarean Data…
• Approximately 40,000 cases/year in registry (CPT: 01961 & 01968 only)
• 35 sites currently submitting cesarean delivery data
• Plans to create a phenotype to identify labor epidural cases that converted to c-section
• Likely missing many conversion cases in this analysis
Call for Measure Build: Survey Results* (8 responses)
#1: Prolonged hypotension before cesarean delivery: 4.38/5.00
#2: General Anesthesia Rate for Cesarean Delivery: 3.63/5.00
#3: Non-opioid adjunct used for post cesarean delivery pain: 3.38/5.00
#4: Antibiotic Timing for cesarean delivery: 3.25/5.00
#5: First temperature in PACU for cesarean delivery: 3.13/5.00
#6: PONV in PACU for cesarean delivery: 3.13/5.00
*All scores reported as mean using Likert scale (1-5).
Prolonged Hypotension before Cesarean Delivery
• Measure Time Period:
– Spinal placement time to delivery of neonate OR
– Spinal placement time to procedure start (incision)
• Hypotension Definition:
– SBP < 90mmHg or <100mmHg; >20% decrease for pre-eclampsia patients (identified using ICD 10 codes)?
• Prolonged:
– 5 or 10 minutes?
• Inclusions:
– Patients undergoing anesthesia for cesarean section (CPT: 01968 & 01961); includes epidural, spinal, combined spinal epidural, & general anesthesia cases for
cesarean section delivery
• Exclusions:
– Emergency c-sections with diagnosis of placental abruption (O45*), Rupture of uterus (spontaneous) before onset of labor (O71.0), Newborn affected by intrauterine
blood loss from ruptured cord (P50.1), Abnormal uterine or vaginal bleeding, unspecified (N93.9), Placenta previa with hemorrhage, third trimester (O44.13),
Hemorrhage from placenta previa, antepartum condition or complication (641.13), Hemorrhage from placenta previa, delivered, with or without mention of
antepartum condition (641.11)
• Provider Attribution- Anesthesia providers signed in at:
1. Neuraxial- Spinal performed (50680), if not available then
2. AACD Procedure Start Date/Time (50006), if not available then
3. Obstetrics- Uterine Incision (50357), if not available then
4. Obstetrics- Delivery of Neonate (50358).
General Anesthesia Rate for Cesarean Delivery
• Percentage of cesarean delivery procedures converted to general anesthesia
• Measure Time Period: Neuraxial Start to Neonate Delivery
• Inclusions:
– Elective or Urgent C-Sections (CPT: 01961 & 01968) with neuraxial anesthesia (epidural, spinal, or CSE) with
documentation of intubation, volatile gas, or NMB (indicating conversion to GA)
• Exclusions:
– Patients undergoing emergency cesarean section
– Patients undergoing cesarean section with hysterectomy (CPT: 01969)?
– Contraindications to regional anesthesia including…?
– Documentation of patient request for general anesthesia?
• Proposal: Informational only measure? No threshold/target
General Anesthesia Rate for Cesarean Delivery (continued)
• Provider Attribution: Anesthesia attending signed in at time of conversion to general
anesthesia
• Algorithm to determine responsible provider:
– Placement of endotracheal tube, or supraglottic airway (LMA), if not available
– Anesthesia Induction Start, if not available
– Administration of first NMB dose, if not available,
– Initiation of volatile gas
• Alternative: Refrain from assigning attribution; institution rate only
Antibiotic Timing & Selection for Cesarean Deliveries
MPOG Registry Data: 39,654 cesarean delivery (Oct 2018-Nov 2019)
Antibiotic Timing:
– Percentage of cesarean deliveries with any antibiotic administered within 60
minutes before procedure start: 81.95% (past 12 months)
Antibiotic Selection:
Cefazolin
Cefazolin &
Azithromycin
Ceftriaxone
Ceftriaxone &
Azithromycin
Cefoxitin
Cefoxitin &
Azithromycin
Cefuroxime
Cefuroxime &
Azithromycin
Azithromycin
Only
75.01% 9.01% 0.08% 0.01% 1.15% 0.20% 0.00% 0.00% 1.04%
Other Measures…continue to investigate or move on?
• #3: Non-opioid adjunct used for post cesarean delivery pain: 3.38/5.00
• #5: First temperature in PACU for cesarean delivery: 3.13/5.00
• #6: PONV in PACU for cesarean delivery: 3.13/5.00
Other suggested measure topics from survey:
– Rate of dural puncture during epidural placement
– Adjunctive azithromycin for non-elective cesarean deliveries (C/SOAP trial)
– TXA administration when EBL > specified amount (TBD)
– Transfusion rates
– Intraoperative Core Temperature Monitoring
– Intraoperative Active Warming
– Intraoperative sedation medication administration for cesarean delivery
– Rate of emergency c-sections after CSE with intrathecal opioids
– Rate of anemia prior to elective cesarean delivery
– Rate of success in neuraxial anesthesia in spinal fusion patients
Other Measure Options: SOAP Centers of Excellence Criteria
• Generated by expert consensus & incorporate evidence-based recommendations
• Topics:
– Personnel & Staffing: MPOG does not capture
– Equipment, protocols, & policies: MPOG does not capture
– Cesarean delivery management
– Routine utilization of a pencil-point needle, 25 gauge or less for the provision of spinal anesthesia
– Multimodal analgesia protocols (Non-opioid adjunct used for post cesarean section pain)
– Strategies to prevent intraop maternal and fetal hypothermia (TEMP 01)
– Appropriate antibiotic prophylaxis
– Spinal hypotension prophylaxis and treatment
– Nausea & Vomiting prophylaxis and treatment
– Labor Analgesia
– Use of low-concentration local anesthetic solutions with neuraxial opioids
– Recommendations & Guidelines implementation: MPOG does not capture
– QA & Patient Follow-up: MPOG does not capture
Measure Inclusion Criteria: CPT Considerations
Procedure Types
CPT Anesthesia
Code
(2018)
External Cephalic Version
01958
Vaginal Delivery
01960
Cesarean Section
01961
01968
Labor Epidural
01967
Complex Obstetric Procedures
01962
01963
01969
Abortion Procedures
01964
01965
01966
• Emergent vs. Non-Emergent
• ASA Status?
2020 Goals
• Collaboration with other OB anesthesia groups (SOAP, ASA Task Force for Obstetric
Anesthesia)
• Measure Build: Prioritize & determine ‘ownership’
– Need volunteers to assist with measure build questions
– Approval process
• Potential Toolkit Topics?
Future Meeting Schedule & Membership
• How often should this group meet?
• Create Basecamp forum?
• 2020 Existing Meetings:
Quality Committee Meetings (Webex)
• February 24
• April 27
• June 22
• August 24
• October 26
MPOG Collaborative Meetings (In-person)
• March 27, Schoolcraft College, Livonia, MI
• July 17, Henry Center East Lansing, MI
• October 2, ASA-Washington DC
THANK YOU!
Kate Buehler, MS, RN, CPPS
MPOG Clinical Program Manager
kjbucrek@med.umich.edu
Special thanks to Dr. Joanna Kountanis for her input in preparing this material.
Nirav Shah, MD
MPOG Associate Director
nirshah@med.umich.edu
ASPIRE Measures including Obstetric Cases
• AKI 01 (c-sections only): Percentage of cases that baseline creatinine increased more than
1.5 times within 7 postoperative days or the baseline creatinine level increased by ≥ 0.3
mg/dL within 48 hours after anesthesia end.
• MED 01: Percentage of cases that required the use of nalaxone or flumazenil for medication
overdose.
• BP 01 (c-sections only): Percentage of cases where intraoperative hypotension (MAP < 55
mmHg) was sustained for less than 20 minutes.
• BP 02 (c-sections only): Percentage of cases where gaps greater than 10 minutes in blood
pressure monitoring are avoided.
• BP 03 (c-sections only): Percentage of cases where intraoperative hypotension (MAP < 65
mmHg) was sustained for less than 15 minutes
• CARD 02 (c-sections only): Percentage of cases with elevated postoperative Troponin levels
or documentation of perioperative myocardial injury.
ASPIRE Measures including Obstetric Cases
• CARD 03 (c-sections only): Percentage of high cardiac risk cases with significantly elevated
postoperative troponin levels.
• FLUID 01-NC: Percentage of non-cardiac cases in which colloids were not administered
intraoperatively.
• GLU 01 (c-sections only): Percentage of glucose labs with perioperative glucose > 200 mg/dL
with administration of insulin or glucose recheck within 90 minutes of original glucose
measurement.
• GLU 02 (c-sections only): Percentage of glucose labs with perioperative glucose < 60 with
administration of dextrose containing solution or glucose recheck within 90 minutes of
original glucose measurement
• NMB 01 (c-sections with GA only): Percentage of cases with a documented Train of Four
(TOF) after last dose of non-depolarizing neuromuscular blocker.
ASPIRE Measures including Obstetric Cases
• NMB 02 (c-sections with GA only): Administration of neostigmine, Sugammadex, and/or
edrophonium before extubation for cases with nondepolarizing neuromuscular blockade
• PONV 01 (c-sections with inhalational GA only): Percentage of patients, aged 18 years and
older, who undergo a procedure under an inhalational general anesthetic, AND who have
three or more risk factors for post-operative nausea and vomiting (PONV), who receive
combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents
of different classes preoperatively or intraoperatively.
• PONV 02 (c-sections with inhalational GA only): Percentage of patients aged 3 through 17
years of age, who undergo a procedure under general anesthesia in which an inhalational
anesthetic is used for maintenance AND who have two or more risk factors for post-
operative vomiting (POV), who receive combination therapy consisting of at least two
prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or
intraoperatively.
ASPIRE Measures including Obstetric Cases
• PONV 03: Percentage of patients, regardless of age, who undergo a procedure and have a
documented nausea/emesis occurrence postoperatively OR receive a rescue antiemetic in
the immediate postoperative period.
• PUL 01 (c-sections with GA-ETT only): Percentage of cases with median tidal volumes less
than 10ml/kg.
• PUL 02 (c-sections with GA-ETT only): Percentage of cases with median tidal volumes less
than 8ml/kg.
• PUL 03 (c-sections with GA-ETT only): Percentage of cases in which Positive End Expiratory
Pressure (PEEP) is used for patients undergoing mechanical ventilation during anesthesia.
• SUS 01 (c-sections with inhalational GA only): Percentage of cases with mean fresh gas flow
(FGF) equal to, or less than 3L/min, during administration of halogenated hydrocarbons
and/or nitrous oxide.
ASPIRE Measures including Obstetric Cases
• TEMP 01 (c-sections only): Percentage of cases that active warming was administered by the
anesthesia provider- includes fluid warming for c-sections
• TEMP 02 (c-sections with GA only): Percentage of cases with increased risk of hypothermia
that the anesthesia provider documented core temperature.
• TOC 01 (c-sections only): Percentage of patients who undergo a procedure under anesthesia
in which a permanent intraoperative anesthesia staff change occurred, who have a
documented use of a checklist or protocol for the transfer of care from the responsible
anesthesia practitioner to the next responsible anesthesia practitioner.
• TOC 03 (c-sections only): Percentage of patients, regardless of age, who undergo a
procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from
the anesthetizing location, who have a documented use of a checklist or protocol for the
transfer of care from the responsible anesthesia practitioner to the responsible ICU team or
team member
ASPIRE Measures including Obstetric Cases
• TRAN 01 (c-sections only): Percentage of cases with a blood transfusion that have a
hemoglobin or hematocrit value documented prior to transfusion.
• TRAN 02 (c-sections only): Percentage of cases with a blood transfusion that have a
hemoglobin or hematocrit value documented prior to transfusion.
• Transfusion measures apply the following exclusion for c-sections:
– Exclude patients undergoing cesarean section (CPT: 01961, 01968, 01962, 01963, 01969) with an EBL >
1500cc.
– Exclude patients undergoing cesarean section (CPT: 01961, 01968, 01962, 01963, 01969) with a HR>110,
SBP<85, DBP<45, or O2Sat <95%.
– Exclude postpartum hemorrhage cases (ICD-10 code: O72.0, O72.1, O72.2, O72.3).